Improv Improving Pre ing Pregn gnan ancy cy Outco Outcomes mes Upda Update fr te from MCH om MCHB Han Hani K. i K. Atra Atrash sh MD, MD, MP MPH Direct Director or Division of Healthy Start and Perinatal Services (DHSPS) Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB) Grantmakers In Health Meeting on Improving the Health of Parents, Children, and Families through Public-Private Collaboration Washington, DC, December 10, 2014 1
Th The e Goo ood d News ews • Inf nfan ant Mo Mortali tality ty Rat ate e de decre reas ased ed by by 12 12.2% 2% from om 20 2000 00 to 20 o 2011 11 • Bet etwee een n 20 2006 06 an and 2 d 201 012: 2: Pret eterm erm deliv livery ery rate e decrea reased d by 9.8% o Low birth th weight ght rate e dec ecreased ased by 3.3% o 2
Th The Continuing tinuing Challeng allenges es Persistent health disparities Other countries have achieved better outcomes Worsening maternal outcomes contribute to poor pregnancy outcomes 3 3
Black-White ite dispari aritie ties s in perina natal tal outcome omes s - United ed States tes 1980 to 2010 2.4 1.9 1.6 Year
Ot Othe her r Co Countries untries Ha Have ve Do Done ne it! t! Compared to the United States: 27 countries have lower IMRs 35 countries have lower PTB Rates, and >50 countries have lower MMRs 5 5
Contributors to Pregnancy Outcomes • Socioeco econo nomic mic stat atus: s: household income, occupational status, or parental educational attainment • Ri Risky behaviors: iors: maternal cigarette smoking, delayed and inadequate utilization of prenatal care, alcohol and drug use • Mater ternal al conditi tions: ons: psychological stress, stressful life events or perceived stress or anxiety during pregnancy, chronic conditions, perinatal infection 6
Source: CDC/NCHS, Mortality Data. 2011 data are preliminary. Prepared by MacDorman for SACIM, November 2012. 7
U. U.S. Ma Materna nal l Mo Mortalit lity 40 35 Maternal Deaths per 100,000 Live Births Total White Black 30 25 20 16.1 15 13.3 10 8.2 5 0 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 Source: Singh GK. Maternal Mortality in the United States. A 75th Anniversary Title V Publication. HRSA 2010 8 8
Severe vere Matern ternal al Morbidity bidity • Severe maternal morbidity increased by 75% and 114% for delivery and postpartum hospitalizations respectively from 1998-99 to 2008-09 • Rates increased during delivery hospitalizations for: o Thrombotic embolism o Acute renal failure (97%) (72%) o Shock (101%) o Respiratory distress o Blood transfusion (183%) syndrome (75%) o Aneurysms (195%) o Cardiac surgery (75%) Callaghan et al: Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 120:1029-36, 2012 9
Risk sk factors ctors for r adver verse se pre regn gnanc ancy y outcom tcomes es amo mong ng wom omen en who ho recen cently tly del eliver vered ed a live ve-bo born rn bab aby y – PRAMS AMS 200 004 4 – Prec econ onception ception hea ealt lth h con onditions ditions and nd beh ehavi viors rs Behavior /Condition % Behavior /Condition % Overweight or obese 35 Previous preterm delivery 11.9 Diabetes 1.8 Asthma 6.9 Tobacco (3 months bef preg) 23.2 Hypertension 2.2 Alcohol (3 months bef preg) 50.1 Heart problems 1.2 Multivitamins (>=4/week) 35.1 Anemia 10.2 No contraception / not 53.1 planning Previous Low Birth weight 11.6 Pre-pregnancy counseling 30.3 Centers for Disease Control and Prevention: Preconception and Interconception Health Status of Women Who Recently Gave Birth to a Live-Born Infant --- Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 Reporting Areas, 2004. MMWR 2007:56(SS10);1-35 10
We Currently Intervene Too Late Critical Periods of Development Weeks gestation from LMP 4 5 6 7 8 9 10 11 12 Most susceptible Central Nervous System Central Nervous System time for major malformation Heart Heart Arms Arms Eyes Eyes Legs Legs Teeth Teeth Palate Palate External genitalia External genitalia Ear Ear Mean Entry into Prenatal Care Missed Period 11
Early prenatal care is not enough, and in many cases it is too late! 12
Working smarter • Implement what we know works • Work beyond the 9 months of pregnancy: Comprehensive women’s health Preconception / interconception Across the life span - “Life -course approach” How we do it: • Consider multiple contributing factors COINs Collective impact 13 13
Lifecourse Perspective to Improve Pregnancy Outcomes The lifecourse approach proposes that disparities in birth outcomes are the consequences of differential developmental trajectories set forth by early life experiences and cumulative allostatic load over the life course. Source: Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30. 14
Lifecourse Perspective to Improve Pregnancy Outcomes Scientifi ntific c evidence ce fro rom m two wo leading longitud tudinal inal models: s: Th The early ly progr gramm mmin ing g model - exposures in early life could influence future reproductive potential Th The cumula lativ ive e pathw hway ays s model - decline in reproductive health results from cumulative wear and tear to the body’s allostatic systems These two models are not mutually exclusive Source: Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30. 15
Li Life fe Co Course urse Pers erspective pective Source: Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30. 16
Source: Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30. 17
Key H HRSA SA Im Improving roving Pregnancy egnancy Ou Outcom tcome e P Programs ograms • SA SACI CIM • Women’s Health Preventive Services Clinic ical al Care Guide delin lines es • Th The Natio iona nal l Mater erna nal l Health lth Initia tiative tive • Th The Infan fant t Morta tality lity COIIN, IN, and • He Healthy thy St Start 18 18
Recommendations for HHS Action and Framework for a National Strategy to Reduce Infant Mortality SACIM Strategic Directions: 6 Big Ideas (1/2013) 1. Improve the health of women. 2. Ensure access to a continuum of safe and high quality, patient-centered care. 3. Redeploy key evidence-based, highly effective preventive interventions to a new generation. 4. Increase health equity and reduce disparities by targeting social determinants of health through investments in high- risk communities and initiatives to address poverty. 5. Invest in adequate data, monitoring, and surveillance systems to measure access, quality, and outcomes. 6. Maximize the potential of interagency, public-private, and multi-disciplinary collaboration. 19
Women’s and Maternal Health - HR HRSA SA I Initia itiativ tives es Women’s Health Preventive Services Clinical Visit Guidelines • Support the development of clinical preventive health guidelines for well woman visit • Compile the guidelines into a succinct resource • Disseminate these guidelines and promote their adoption into standard clinical practice among women’s health care providers 20
Women’s and Maternal Health - HR HRSA SA I Initia itiativ tives es Nation onal al Matern rnal al Health th Initi itiati ative ve • Promote coordination and collaboration within HRSA, across HHS agencies and with professional and private organizations. • Five priorities: Improve women’s health before, during, and after pregnancy Improve systems of maternity care including clinical and public health systems Improve public awareness and education Improve research and surveillance Improve the quality and safety of maternity care 21
Women’s and Maternal Health - HRSA I Initi itiat ativ ives es Improv ovin ing g Mater erna nal l Health th and Sa Safet ety • Purpose: reduce the number of maternal deaths and/or preventable severe morbidities • Goal: engaging health care providers, State leaders, hospitals, payers, and consumers • Strategies: o Promote knowledge of and access to preconception and interconception care through a provider education campaign o Engage stakeholders in efforts to reduce primary cesarean delivery o Facilitate the adoption of the maternal safety bundle through development of a CoIIN of early adopter states 22
THE NATIONAL HEALTHY START PROGRAM History • Established in 1991 as a presidential initiative • Provides funding and supports communities with high infant mortality rates and other adverse perinatal outcomes • Focused on community innovation and creativity and encouraged communities to do what was best for them • Today, HRSA supports healthy start projects in 196 communities 23 23
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